25th IVR World Congress LAW SCIENCE AND TECHNOLOGY Frankfurt am Main 15–20 August 2011 Paper Series No. 094 / 2012 Series C Bioethics / Medicine / Technology / Environment Carolina Pereira Sáez Principlism: Bioethics as Procedure? 1 URN: urn:nbn:de:hebis:30:3-249526 This paper series has been produced using texts submitted by authors until April 2012. No responsibility is assumed for the content of abstracts. Conference Organizers: Edited by: Professor Dr. Dr. h.c. Ulfrid Neumann, Goethe University Frankfurt am Main Goethe University, Frankfurt/Main Department of Law Professor Dr. Klaus Günther, Goethe Grüneburgplatz 1 University, Frankfurt/Main; Speaker of 60629 Frankfurt am Main the Cluster of Excellence “The Formation Tel.: [+49] (0)69 - 798 34341 of Normative Orders” Fax: [+49] (0)69 - 798 34523 Professor Dr. Lorenz Schulz M.A., Goethe University, Frankfurt/Main Carolina Pereira Sáez, A Coruña / Spain 1 Principlism: Bioethics as Procedure? Abstract: In their book Principles of Biomedical Ethics, Tom Beauchamp and James Childress offer an account of bioethics, called “Principlism”, by way of specifying and balancing four clusters of principles.2 These principles are found, as the author state, in a common morality, understood as a set of universally shared moral beliefs. This paper seeks to introduce the following questions: Does this account of Beauchamp and Childress flow from common morality in a natural way? Can their proposals claim to be endorsed by the authority of common morality? If not, in what way does Principlism contribute to bioethics? Keywords: Bioethics, Principlism, Common Morality. I. What does Principlism propose? Principlism, or the Four-Principles approach to bioethics, is the particular school of bioethics developed by Beauchamp and Childress’ Principles of Biomedical Ethics.3 Beauchamp and Childress claim that it is possible to identify four basic moral principles to be used as starting points for practical decision-making in biomedical hard cases.4 Principlism may be properly understood as an answer to the lack of consensus among ethical perspectives that can be found in the United States of America since the middle of the twentieth century. Considered as an answer, it offers to the perplexed practitioner the universality of its principles: “(1) Respect for autonomy (a norm of respecting and supporting autonomous decisions), (2) nonmaleficence (a norm of avoiding the causation of harm), (3) beneficence (a group of norms pertaining to relieving, lessening, or preventing harm and providing benefits and balancing This piece is part of the ongoing research project “Principialismo y teoría de la argumentación en la toma de decisiones biomédicas” (DER 2010-17357/JURI) financed by the Ministerio de Ciencia e Innovación of Spain. It was presented as a paper in the XXV World Congress of Philosophy of Law and Social Philosophy (Frankfurt am Main, August 2011). Orality has been preserved but footnotes have been added. Some of the arguments expounded are provisional and all are open to discussion. The author will thank any criticism. Acknowledgments: Pedro Serna (Universidade da Coruña, Spain), Richard Stith (Valparaiso University, Indiana, USA). 2Tom Beauchamp and James Childress, Principles of Biomedical Ethics (6ª. ed.), Oxford University Press, 2009, 25. 3 Although Beauchamp and Childress are not the only supporters of Principlism and this book is not their only contribution to it, this article focuses on the sixth edition of Principles of Biomedical Ethics. On different accounts of bioethics based on principles, see Viviana García, PhD dissertation El consentimiento informado del paciente menor o incapaz, A Coruña, Universidade da Coruña, 2011, 62-72. 4 See Beauchamp (note 2), 1-2. 1 benefits against risks and costs), and (4) justice (a group of fairly distributing benefits, risks and costs)”5. These principles are put forward to express the general norms of common morality,6 which, in its turn, is understood as the set of norms shared by all persons committed to morality.7 They are suitable for solving hard biomedical cases among people who support different ethical theories. So the relevant question seems to be this: How can these principles be universally accepted in conditions of deep ethical disagreement? From the principlist point of view, what we must do in order not to disturb this universal agreement about the Four Principles is to let aside our theoretical inquiries about its foundations. According to Beauchamp and Childress, the lack of moral consensus is more a theoretical than a practical question: “Convergence as well as consensus about principles among a group of persons is common in assessing cases and framing policies, even when deep theoretical differences divide the group”.8 These theoretical differences do not prevent reaching similar practical conclusions, so, at the level of conflict-solving, it does not matter which understanding of the foundations of the principles we support: “Reasons exist […] for holding that […] distinctions among types of theory are not as significant for practical ethics as some seem to think”.9 So in most cases ethical differences would be only theoretical differences, and therefore would not be much relevant: to solve practical biomedical questions, we can lay theories aside. Indeed, even if a fully satisfactory general ethical theory were available, practical questions would remain largely unaffected by it.10 So far the principlist proposal may be summarized as follows: In order to face up to the lack of ethical consensus and yet solve practical biomedical questions, we must look for a common morality, general moral beliefs universally shared. There we will find all the general norms we can expect to solve our bioethical dilemmas. Nevertheless the Four Principles, although expressing norms about right and wrong in human actions, do not suffice to solve all biomedical cases. As a part of the common morality, principles are abstract, universal and content-thin norms, and “abstract norms do not contain enough specific information to provide direct and discerning guidance”.11 The Four Principles are only a spare starting point for the development of more specific norms of conduct. For the purpose of addressing particular problems and contexts, they need to be 5 Beauchamp (note 2), 12-13. 6 See Beauchamp (note 2), 12. 7 See Beauchamp (note 2), 3. 8 Beauchamp (note 2), 362. 9 Beauchamp (note 2), 363. 10 See Beauchamp (note 2), 1-2. 11 Beauchamp (note 2), 9. 2 interpreted and implemented. There is a further, two-fold feature of the Four Principles that explains their need of development: they are all equally binding but only prima facie. No one is a supreme moral value, overriding all other conflicting values. So, in particular circumstances, all principles can be justifiably overridden by moral norms with which they conflict,12 insofar as they create an equal or stronger obligation. In those cases, agents must locate “the greater balance” of right over wrong by comparing the weights of competing norms. So as abstract and prima facie norms, principles have limits, limits that explain “the need to give them additional content”,13 by way of specification and balancing. II. The common morality as the set of universally shared beliefs Before paying attention to the way Beauchamp and Childress, by means of specification and balance, propose to construct an applied ethics, we might focus on the following question: if the four clusters of principles, as general norms for biomedical ethics, are so universally accepted, how do our ethical differences — even if only theoretical — occur? Let us put it the other way round: Is it true, as Beauchamp and Childress state, that the Four Principles are universal, part of a common morality that “is applicable to all persons in all places, and we rightly judge all human conduct by its standards”?14 From where does this common morality derive its authority? The authors do not attempt to justify the correctness or authority of the common morality. They just affirm, as a matter of fact, that some general norms are universally adhered to, but they realise that universal agreement does not render norms eo ipso authoritative.15 In fact, they hold that common morality includes just moral beliefs, not objective standards prior to moral beliefs.16 Beauchamp and Childress do not try to offer reasons why common morality is or should be universally accepted, but just depict the factual situation of some moral beliefs being shared by all persons committed to morality. They just affirm that the norms of the common morality “have proven over time that their observance is essential for stability and civilized interaction”.17 And it is precisely because we are already convinced about this that “the literature of ethics does not usually debate the merit or acceptability of these basic moral commitments”.18 But this does not imply the claim that the moral norms of all societies are indistinguishable: only the most general and basic elements of morality are universally shared. 12 See Beauchamp (note 2), 14-15. 13 Beauchamp (note 2), viii. 14 Beauchamp (note 2), 3. 15 See Beauchamp (note 2), 394. 16 See Beauchamp (note 2), 4. 17 Beauchamp (note 2), 394. 18 Beauchamp (note 2), 3. 3 Moreover, “debates do occur about their precise meaning, scope, weight, and strength […]”.19 (This basic content of morality, precisely as universal, can also be found in most classical ethical theories). To be applied, these basics elements of morality need to be developed